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Bullying: the silent epidemic in the NHS

Roger Kline, 15 May 2013

One quarter of the staff in the largest employer in Europe report that they were bullied at some point in the previous 12 months. The rate of reported bullying has doubled in just four years. It is some three times higher than elsewhere in employment. Such bullying is held to be directly responsible, in part, for the largest ever UK healthcare scandal in which hundreds of patients died.

But almost no one wants to talk about it.

The Mid Staffordshire NHS Trust Public Inquiry considered research which interviewed some 50 very senior NHS stakeholders and concluded that a “pervasive culture of fear in the NHS and certain elements of the Department for Health” existed throughout the NHS and in parts of the DH, with fear among chief executives of public humiliation or losing their jobs as a prime driver for quality improvement. It concluded:

“The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.”

Robert Francis QC repeatedly referred to bullying as a key driver of the toxic culture at Mid Staffordshire hospital -- yet made not a single recommendation about stopping it. Bullying was not mentioned in the Government’s response to the Francis Report.

In 2009, Sir Ian Kennedy, then departing chair of the Healthcare Commission (now CQC), warned about the “corrosive” impact of bullying among NHS staff. He said bullying worried him “more than anything else” in the NHS and was “permeating the delivery of care”. Sir Ian said bullying was “one of the biggest untalked about problems in the delivery of good care to patients”.

The 2008 NHS staff survey which prompted his remarks showed that 12% of staff said they had suffered bullying, harassment or abuse at work by colleagues in the previous year.

Four years later, two years after the first 2010 Francis report on Mid Staffordshire identified bullying of staff as a key cause of the scandalous treatment of patients, the 2012 NHS staff survey reported that the proportion of staff reporting bullying by colleagues and managers had doubled in just four years.

Last year 24% (almost one quarter) of staff reported they had experienced bullying, harassment or abuse from either their line manager or other colleagues. This was a jump in just one year from 15%.

Moreover, staff surveyed said less than half of cases of bullying, harassment or abuse cases were reported and the proportion of cases being reported is falling, down from 54% in 2004 to 44% now.

In 2009, an NHS Confederation (employers) survey described a “culture of blame”. It reported that “several of our interviewees identified a problem of a perceived or real toxicity in the wider system inhabited by chief executives, describing the environment as 'brutal', 'arbitrary', 'prone to favouritism' and intolerant of risk-taking that isn’t successful.”

In November 2012, another survey of 81 NHS chief executives suggested that the culture of fear reported to Lord Darzi in 2008 pervades the NHS right from the top.
Many respondents describe a “bullying culture”. Another respondent said: “A climate of fear pervades the NHS, driven by ruthless governance and accountability regimes that have little interest in achieving anything other than the avoidance of blame.” Another added: “The fear of speaking out is worse than I’ve known it in over 32 years in the NHS.”

NHS Confederation chief executive Mike Farrar said that, although he was worried by the working culture reflected in the survey results, he was not surprised by the comments. “Bullying is a word whispered in the NHS. Nobody wants to operate under a climate of fear and everybody needs to have a zero tolerance approach.”

Every NHS employer has policies making bullying a disciplinary offence. Yet they are largely ignored and often not even understood.

Bullying is not specifically defined in law, but in their advice leaflet for employees, the statutory body Acas give the following definition: “Bullying may be characterised as offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means intended to undermine, humiliate, denigrate or injure the recipient.”

Bullying or harassment may be by managers or colleagues and may be obvious or insidious. Bullying need not be face to face by can be by phone or email. Whatever form it takes, it is unwarranted and unwelcome to the individual.

ACAS give examples of bullying ranging from undermining, marginalising, ridiculing, excluding, victimising, micromanaging, overloading, blocking development, physical threats or unwanted sexual advances. NHS staff surveys report BME and disabled staff are bullied more than other staff.

Not only is bullying widespread at every level, but there is some evidence that a particular type of “corporate psychopath” may be responsible for a disproportionate amount of bullying. One article described such people as a “threat to the development of a sense of corporate social responsibility because they have no sense of guilt, shame or remorse about the consequences of their decisions".

One writer noted last year: "One could forgive an outsider’s bemusement at how it is that a modest number of NHS managers succeeded in creating such a hostile environment that only 11% of doctors have confidence in whistleblowing protection. If the majority of the powerful in medicine (which includes doctors as well as managers) believed that whistleblowers were a gift rather than a curse to the profession then the culture of fear would be overthrown and the problem would cease to exist."

Part two of this blog will consider the causes of this epidemic, its impact on patients and staff, and what can be done about it.

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